Appalachian and rural underserved residents, in general, experience higher rates of multiple morbidities (MM) with fewer resources to prevent and manage disease. Some researchers have speculated that the well-documented cancer health disparities affecting Appalachians may be attributable to multiple morbidity management demands which may deprioritize essential and efficacious cancer screenings. In this pilot study, we examine whether and how multiple morbidities affect colorectal cancer screening rates. Our long-term goal is to turn this disadvantageous situation of competing time and resource pressure into an advantage by increasing cancer screening services during the more frequent medical interactions of those with multiple morbidities. Addressing the nearly three-quarters of middle aged and older adults with MM is essential due to skyrocketing rates of MM, higher rates of cancer mortality among those with MM, and competing demands of disease prevention and management. We aim to expand our limited understanding of the association between MM and colorectal cancer (CRC) screening through three research activities. First, to obtain rich insights into the factors and circumstances that affect patterns of CRC screening behavior among those with multiple morbidities, in-depth interviews will be conducted with 5 health care providers representing diverse practices in Appalachia and with 40 patients who have two or more chronic diseases. These interviews will provide locally grounded perspectives from the two most salient health decision makers, providers and patients. Second, to insure generalizability, we will assess the impact of factors germane to both MM and CRC screening behavior by conducting a stratified representative survey of Appalachians. Finally, after identifying factors, circumstances, and patterns that prevent CRC screening in the context of multiple morbidities, we will hold focus groups to validate our findings and discuss optimal direction for interventions. Ultimately, these findings will lead to the development of a community-based participatory intervention R01 that will capitalize on the relatively frequent medical care visits of those with multiple morbidities and ultimately will increase CRC screening, improve practice coordination, and decrease cancer-associated deaths. PUBLIC HEALTH RELEVANCE: In the US, the majority of the ever-growing middle aged and older population has multiple morbidities or several chronic diseases. Having multiple morbidities generally decreases the likelihood of receiving highly effective cancer prevention, like colorectal cancer screening. This project uses innovative methods to determine the reasons why those with multiple morbidities may be less likely to get colorectal cancer screening and will eventually develop a culturally consistent intervention for the underserved rural health disparities population of Appalachia to increase early detection of this deadly cancer.